Radiologic imaging and biomarker indices in detecting liver fibrosis in thalassemia: a systematic review of diagnostic accuracy

Abstract Background Radiologic imaging, particularly transient elastography (TE), has emerged as a key non-invasive approach for assessing liver fibrosis in patients with thalassemia, in whom repeated liver biopsy may be impractical. Serum biomarker indices are also used as alternative or adjunctive tools; however, their diagnostic performance has not been comprehensively summarized. Aim of the work This systematic review evaluated the diagnostic accuracy of radiologic imaging techniques and biomarker indices for detecting and staging liver fibrosis in thalassemia. Methods Literature searches were performed in PubMed, Scopus, CENTRAL, and EMBASE via Ovid, following PRISMA-DTA guidelines. Extracted outcomes included the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity, and risk of bias was assessed using QUADAS-2. Results Nine studies involving 500 patients with thalassemia and 12 diagnostic modalities were included. Notably, while the systematic search encompassed all radiologic imaging modalities, TE was the sole imaging technique evaluated. For detecting fibrosis (≥ F1), TE with Fibrosis-4 score (TE-FIB-4) outperformed biomarker indices alone, while TE alone showed variable results. Several biomarker indices showed promising results for differentiating significant fibrosis (≥ F2) and advanced fibrosis (≥ F3); however, reference standards, including TE, did not consistently achieve diagnostic accuracy comparable with liver biopsy. For cirrhosis (F4), TE with cutoff values of 11–13 kPa and combined approaches (TE with aspartate aminotransferase-to-platelet ratio index [TE-APRI] and TE-FIB-4) showed promising accuracy. Conclusions Overall, TE-FIB-4 may assist in identifying fibrosis (≥ F1), whereas TE-based modalities, alone or combined, may aid in diagnosing cirrhosis (F4). Evidence remains limited by small sample sizes, heterogeneous reference standards, and limited diversity of imaging modalities, highlighting the need for further imaging-focused studies.